Rebalancing Mental Health and Developmental Disability Services

2. Re-Balancing the Service System for People with Mental Illness, Developmental Disabilities and Addictive Diseases (MHDDAD)

3. What is MHDDAD?

4. Department of Human Resources Division of Mental Health, Developmental Disabilities and Addictive Diseases 5 MHDDAD Regional Offices 7 State Hospitals Community Providers

6. Who we serve: Children & Adults with: serious mental illness developmental disabilities addictive diseases

7. Funding Sources • State funds • Federal Block Grant funds • Medicaid funds • Medicare funds • Private insurance / private pay • County funds • Various public and private grants

8. MHDDAD Services for children & adolescents

9. MHDDAD Children & Adolescents Services • Preserve families • Avoid hospitalization • Support participation in everyday life

10. Community Services - C&A Served Serious Emotional Disturbances

11. Community Services - C&A Served Addictive Diseases

12. Hospital Services - C&A Served Serious Emotional Disturbances

13. Services for adults with mental illness and/or addictive diseases

14. Adults (MH &AD) Services • Best Practices • Transition from institutions • Assure availability of medication

15. Community Services - Adults Served Mental Health

16. Community Services - Adults Served Addictive Diseases

17. Hospital Services - Adults Served Mental Health

18. Services for people with developmental disabilities

19. Developmental Disabilities Services • Reduce the waiting list • Transition from institutions • Ensure provider availability • Ensure community capacity

20. Community Services - Adults Served Developmental Disabilities

21. Community Services - C&A Served Developmental Disabilities

22. Olmstead ‘99 Consumers with DD Served in State Hospitals Note: FY07 Data is Oct. 31, ‘06 Source: BHIS Dec.’06 HB

23. Developmental Disabilities Waiver Planning List Persons Waiting for Waiver Services Nov. ‘06 Source: MHDDAD Dec. ’06 HB

24. Forensic Services

25. Forensic Services • Ensure timely movement from jails • Ensure appropriate treatment setting

26. State Mental Health Administrators in the major of the states report increasing percentages of forensic patients in state hospitals. Source: State Profile Highlights: National Association of State Mental Health Program Directors Research Institute, Inc. (NRI)

27. Why does the system need to be re-balanced?

28. Old Paradigm • Isolation of people with mental illness, addictive diseases and developmental disabilities in hospitals and institutions • Use of hospitals as the preferred treatment forced people and resources into “deep end” services • Example: Central State Hospital housed 13,000+ people in the 1960s. Today’s system of 7 hospitals has 2,513 beds

29. Old Paradigm • Historical grant-in-aid funding to CSBs not driven by need, demographics or outcomes • Children not considered priority customers • Lack of accountability for the people most in need getting effective services

30. New Paradigm • People served as close to home, family and community as possible • Provider competition affords greater consumer choice • Fee for service and utilization review ensure that the right people are getting the right services in the right amount at the right price • Children get their fair share of the resources • Nobody should live in a hospital (particularly children and people with developmental disabilities)

31. Hospitals are our Burning Platform • Public behavioral health system is the “safety net” when private systems are exhausted • Increased demand for substance abuse treatment is driving people into deep end services such as emergency rooms and state hospitals • Courts are increasingly relying on state hospitals • Mental illness causes more disability than any other class of medical illness in America.

32. Georgia’s Mental Health System… …is about 8 years behind other states in transitioning resources to community-based services …only since 2001 has Georgia been spending more resources on community services than hospital services

33. Burning Platform • Children are hospitalized at 3X the national rate Adults are hospitalized at 3.5X the national rate Elderly are hospitalized at 24X the national rate • 417 people currently in state hospitals could be discharged, but lack needed community services • People are living in hospitals - 66% have been in the hospital for over 1 year; 25% for 10+ years

34. Burning Platform • Hospital readmission rates are twice the national rate • Currently exceeding forensic bed capacity by 35% (164 beds). Projecting a 89% capacity shortfall by 2010 (417 beds) • 64% of forensic consumers have had previous MHDDAD contact = missed opportunity • Resources of other systems are drained • Examples: Sheriff’s Offices, DFCS, DJJ, DOE, local emergency rooms

35. Burning Platform • 2001 - Revenue Maximization projected Medicaid revenue would replace $37.4M in state funds annually (did not occur) • Medicare earnings were over-projected due to seriously mentally ill consumers exhausting their lifetime benefit • Because public system is “safety net” when other resources are exhausted, most consumers come with no insurance or ability to pay • Olmstead Decision accelerated community placements • Escalating costs – utilities, medical treatment , staff…

36. Actions Taken • Consistent statewide set of standards for the community: • Defined who will be served • What basic services will be available to all Georgians • Redistributed funding so every area gets their fair share

37. Actions Taken 2)Created a front door to service system: • Established Single Point of Entry (1-800-715-4225) • Funded Crisis Intervention Training for 20% frontline law enforcement officers to divert mentally ill from jails • Created 23 hour observation units at 4 hospitals to avoid 66% of hospital admissions • Established crisis stabilization services for children to avoid 60-75% of hospital admissions • Increased adult crisis stabilization services by 30% since FY04

38. Actions Taken • Increased the number of people that can be served in the community: • Steady increase in number of MR/DD waivers • Open competitive market place with fee-for-service to increase # of providers, consumer choice and number of people served • Use of Case Expeditors to safely move consumers from hospitals to the community • External utilization review of hospital and community services to ensure the right services for the right people in the right amount

39. Actions To Be Taken • Reduce the cost of pharmacy operations and medications (estimated annual savings $1.2M) • Operate smaller, more specialized hospitals • Privatize specific services such as billing • Consolidate selected hospital functions • Potential federal funding of Money Follows the Person Grant • Legislative proposal allowing misdemeanor defendantsfound incompetent to stand trialto be evaluated and treated for competency restoration in the community

40. Future Initiatives • Consolidation of MHDDAD and DFCS child and adolescent behavioral health systems - positioning MHDDAD to provide treatment and DFCS to provide protection • Consolidation of MHDDAD and Public Health substance abuse prevention services - positioning DHR to impact health behaviors

41. Current System $4.9M funding 142 inpatient beds Length of stay 9-12 months 150-200 adolescents served annually New System $2.5M funding 32 inpatient beds Length of stay 3-6 months 120-150 children served annually $2.4M funding Outpatient, community-based services 1,350 adolescents served annually Future InitiativesRestructuring Child & Adolescent Substance Abuse Services

42. Future Initiatives • Sheriff’s Tele-medicine Pilot • technology to link Sheriff’s Offices and state hospitals; only transport those who must be moved • Crisis Services for children • add mobile crisis services and funds to purchase additional crisis beds

43. Future Initiatives • Child & Adolescent Parent-to-Parent Peer Support Program: • links parents of emotionally disturbed children with other parents who have successfully navigated the service delivery system • Increase Medicaid waiver service slots and expand supports to families & consumers with the new developmental disability waiver: • Individual Budgets • Supports Intensity Scale • Choice of Services • Financial Support Services

44. Characteristics of the Reformed System • Every area of the state will have: • A true single point of entry • Crisis stabilization for children and adults • A set of core services • Deinstitutionalization of developmentally disabled and long term mental health consumers • Individualized treatment planning and utilization management • Maximum self-sufficiency and independence for adults with appropriate supports